Financial Planning Questionnaire A
Personal Details Are you fluent in English? Yes No Yes No Do you require the assistance of an interpreter? Yes No Yes No Title (e.g. Mr, Mrs) Surname Given name Preferred name Gender Male Female Male Female Marital status Date of birth (DD/MM/YYYY) / / / / Retirement age Relationship between clients 1 and 2 Residential address State Postcode State Postcode Postal address (write as above if same as residential address) State Postcode State Postcode Home telephone Business telephone Mobile Email address Facsimile Preferred contact method Are you an Australian resident for taxation purposes? Yes No Yes No If no, which country? Family Position Name Date of Birth Relationship Financial Dependants When Would You Expect Dependency to Cease? Third Parties
Employment Details Occupation Breakdown of occupation duties (administration, manual, travel, etc) Employment status Full-time Unemployed Full-time Unemployed Part-time Homemaker Part-time Homemaker Casual Retired Casual Retired Hours worked per week Employer s name Health Smoker Yes No Yes No Do you have private health insurance? Yes No Yes No If yes, please outline the provider details Do you know of, or have you been made aware of, any issues which may be relevant to the assessment of a life insurance application? For example: known medical conditions; occupational hazards; planned overseas travel; engagement in hazardous pursuits; and/or immediate family medical history concerns. Yes No Not disclosed Yes No Not disclosed If yes, please provide details or alternatively complete the Life Insurance Pre-Assessment Request and attach as an addendum to this document.
Assets and Liabilities Alternate assets and liabilities data collection used a Lifestyle and Business Assets Detail Owner Current Value Debt Principal residence Home contents Motor vehicle Holiday house Business goodwill Business (plant, stock & equipment) Superannuation / and Pension Income / Investment Streams Alternate superannuation/income stream data collection used and attached. Please attach an addendum to the back of this document if you are unable to fit all existing funds below. Please attach the Replacement Checklist as an addendum to the back of this document if you are replacing an existing superannuation/income stream. Superannuation Details - Client 1 Owner Fund name/provider Member number Estimated Investment balance option(s) Superannuation Details - Client 2 Owner Fund name/provider Member number Estimated Investment balance option(s) 1 2 3 4 1 2 3 4
Current Protection Insurance Details Please attach an addendum to the back of this document if you are unable to fit all existing policies below. Client 1 Life Insured Policy Number Insurer Insured Benefits Cover / Sum Insured Life TPD Trauma IP Client 2 Life Insured Policy Number Insurer Insured Benefits Cover / Sum Insured Life TPD Trauma IP Estate Planning Will Do you have a Will? Yes No Yes No What is the date of your Will? / / / / Is your Will current? Yes No Yes No Power If yes, who of Attorney is (are) the (POA) executor(s)? Do you have a current POA? Yes No Yes No If yes, please state type: Enduring General Enduring General Medical Medical Normal Normal Who is (are) the Attorney(s)?